San Benito — SB-PR-2

Source: https://www.sanbenito.courts.ca.gov/system/files/sbpr2.pdf

SB-PR-2

ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar Number, Address): Reserved for Clerk’s Office Stamp

TELEPHONE NO: FAX NO.(Optional): E-MAIL ADDRESS (Optional): ATTORNEY FOR (Name): SUPERIOR COURT OF CALIFORNIA, COUNTY OF SAN BENITO 450 Fourth Street Hollister, CA 95023

CONSERVATORSHIP OF:

PERSON ESTATE LIMITED CASE NUMBER:

HEARING DATE:

CONFIDENTIAL GENERAL PLAN

Superior Court, County of San Benito requires the General Plan to be filed within ninety (90) days of appointment. If a question does not apply, write “not applicable” or “none.” If you need additional space to fully respond, please note on the form that a separate attachment is being provided and staple the attachment to the form.

I. GENERAL PLAN

Current address of conservatee __________________________________________________________ __________________________________________________________ Telephone __________________________________________________________

Personal Caregiver:

If the Conservatee has a personal caregiver, please state:

Is the care provider a family member(s)? Yes No. If so, is the family member(s) paid? Yes No Is the care provider(s) employed by an agency? Yes No. If yes, what agency?________________________________ Is the care provider(s) a private hire? Yes No Who prepares the caregiver’s paychecks or payroll? (Wages, state & federal taxes, SDI, FICA, etc.)________________________

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Describe conservatee’s general medical condition: generally in good health generally in poor health has developmental disability has head injury has dementia has mental illness substance abuse issues (alcohol, drugs) How often does the conservatee see a doctor? ____________________ Name of doctor? _______________________________

Any other health providers involved? dentist social worker hospice care worker podiatrist visiting nurse psychiatrist/counselor physical therapist speech therapist other (specify)________________________________

Is the conservatee being administered psychotropic medications for the treatment of dementia? Yes No. If yes, has the Court granted the conservator “special dementia powers” as to medication? Yes No. If not, contact your attorney or the Court Investigator’s Office.

Form Adopted for Mandatory Use CONFIDENTIAL GENERAL PLAN Superior Court of California, County of San Benito SB-PR-2 [eff. 1/1/20] page 1 of 3

SB-PR-2 Is the conservatee placed in a secured perimeter or locked facility with no freedom of egress? Yes No. If yes, has the Court granted the conservator “special dementia powers” as to placement? Yes No If not, contact your attorney or the Court Investigator’s Office.

Activities (Describe the normal activities of the conservatee): School - Name: ______________________________________________________________________________________ Day Program - Name: __________________________________________________________________________________ Employment - Name: ___________________________________________________________________________________ Conservatee unwilling to participate Conservatee unable to participate

Visitation: How often do you visit the Conservatee?______________________________________________________________________ Do family, friends or neighbors also visit? Yes No. If yes, please explain who visits and the frequency of visits:

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Did conservatee express any end-of-life preferences in a California Advance Health Care Directive/Health Care Power of Attorney? Yes No. If yes, what are the expressed wishes? _______________________________________________

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II. FINANCIAL PLAN

Does the conservatee have a trust? Yes No If yes, is it a revocable living trust a special needs trust Has it been funded? Yes No Approximate current value: _______________

Does the conservatee have a Representative Payee? Yes No If yes, Name:___________________________

Does the conservatee receive Medi-Cal benefits? Yes No If conservatee resides out of his/her home, what is the Medi-Cal share of cost? $_____________________

Estimated Monthly Income (to be completed by conservators of person or conservators of person and estate) Social Security/SSI $______________ Dividend Income $______________ Pension $______________ Rental Income $______________ Veteran’s Benefits $______________ Interest Income $______________ Other (specify)______________________ Distributions from Trust $______________ Total estimated monthly income $_______________

Estimated Monthly Expenses

LIVING EXPENSES (to be completed by conservators of person or conservators of person and estate) Rent or Mortgage $____________________________ Telephone/Cell $________________________ Nursing/Care Home $__________________________ Utilities (PG&E, Water, Garbage, Cable TV, etc). $__________ Live-In Attendants $___________________________ Food $________________________ Other Care Providers $_________________________ Transportation and gasoline $________________________ Medical & Dental $____________________________ Laundry & Cleaning $________________________ Medicines $_________________________________ Medical & Dental Supplies $________________________ Clothing $__________________________________ Entertainment (subscriptions, recreation, etc.) $___________ Other: $___________________________________ Total estimated monthly expenses $___________________

Other Expenses (to be completed by conservators of estate or conservators of person and estate)

TAXES Current? Estimated amount Income Yes No $ _______________ Property Yes No $ _______________ Payroll Yes No $________________ INSURANCE Company Premium Paid Coverage Amount Premium Amount Homeowners ____________________ Yes No _______________ $_____________ Renters ____________________ Yes No _______________ $_____________ Auto ___________________ Yes No _______________ $_____________ Health ___________________ Yes No _______________ $_____________ Life ____________________ Yes No _______________ $_____________

Form Adopted for Mandatory Use CONFIDENTIAL GENERAL PLAN Superior Court of California, County of San Benito SB-PR-2 [eff. 1/1/20] page 2 of 3

SB-PR-2 Other ____________________ Yes No _______________ $_____________

III. FINANCIAL MANAGEMENT PLAN

Estimated annual income $ Estimated market value (FMV) of investments $ Estimated FMV of real estate $____________________________________

1. Manner of vesting: Cash accounts Certificates of Deposit Mutual funds Stocks Other? Specify__________________________________________________________________________________________________ Is there a brokerage account? Yes No. If yes, name of brokerage ______________________________________________

2. Estimated annual cost of personal care plan: __________________________________________________________________ If the conservatee’s monthly expenses are greater than monthly income, explain how the shortfall will be met? _______________

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3. Estimated CONSERVATOR’S FEES for the first year? $ _______________ Not Applicable

4. Estimated ATTORNEY FEES for the first year? $ ______________ Not Applicable

5. Anticipated Estate Activities, i.e. Sales of Estate Assets, Change of Investment Plan, Purchase of Real Property, Establishment of a Trust, Amendment to an Existing Trust, etc. _________________________________________________________________

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6. Are there any valuables in the conservatee’s residence that need to be protected? No Yes, if so, describe them and specify what steps have been taken to protect these items from theft or loss. ___________________________________________

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7. What is the surety bond amount? ___________________ Does the bond meet the requirements for cost of recovery to collect on the bond, including attorney’s fees and costs? (Prob. C. §2320 and California Rules of Court 7.207) Yes No (explain)_________________________________________________________________________________________________

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I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.

Dated: _______________________ at ______________________________, California

By: __________________________________________________________, Conservator

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Form Adopted for Mandatory Use CONFIDENTIAL GENERAL PLAN Superior Court of California, County of San Benito SB-PR-2 [eff. 1/1/20] page 3 of 3